Health care coverage: payment for benefits.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law requires a health care service plan to reimburse providers for emergency services and care provided to its enrollees until the care results in stabilization of the enrollee, except as specified, and to reimburse providers for poststabilization care in specified circumstances. Existing law requires group health care service plans to authorize and permit assignment of a Medi-Cal beneficiary's right to reimbursement for covered services to the State Department of Health Care Services, except as specified. This bill would impose that assignment requirement on a group or individual health care service plan, except a plan providing benefits under a specialized health care service plan contract, as defined, and would also require those plans to authorize and permit assignment of an enrollee's or subscriber's right to reimbursement for covered services to the provider furnishing those services, except as specified. The bill would require the provider to provide the plan with certain information in order to receive reimbursement. Because a willful violation of those provisions would be a crime, the bill would impose a state-mandated local program. Existing law provides for the direct payment of group insurance medical benefits by a health insurer to the person or persons furnishing or paying for hospitalization or medical or surgical aid or, in the case of a Medi-Cal beneficiary, to the State Department of Health Care Services, as specified. Existing law requires that the amount of the reimbursement not exceed the amount of the benefit provided by the policy or the amount of expenses incurred on account of the hospitalization or medical or surgical aid. This bill would provide for the direct payment of individual insurance medical benefits by a health insurer, except an insurer providing benefits under a specialized health insurance policy, as defined, to the person who provided the hospitalization or medical or surgical aid where that person has submitted certain information to the insurer for reimbursement. The bill would limit the amount of the reimbursement to the amount of the benefit covered by the policy. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.